[Scientific session research presentation] Assessment completed through real time root cause analysis of every fall. Common risk factors identified prior to the fall included: polypharmacy, medications causing confusion/delirium, history of falls, mobility limitations, and toileting. We shifted from a nursing team to a transdisciplinary team consisting of Leadership, Physicians, Nursing, Pharmacy, Physical Therapy, Maintenance, Safety/Risk. Our focus shifted from falls being an isolated event to a complex clinical syndrome with potential for significant morbidity/mortality that needs to be recognized, evaluated, treated, and prevented.Education included interactive classes, online CME's, and "Equipment Fair". A Post Fall Assessment Team responds to falls 24/7 to examine the risk factors' "real time", serve as a resource, and implement strategies. Limiting sleeping medications on the formulary, administration time prior to midnight, and activating bed alarms was successful. To promote a positive culture, a reward program celebrates "number of days" departments are "falls free". Documentation analysis resulted in the following improvements: admission order sheets revised to decrease automatic ordering of sleep/anxiety medications, assessment forms designed by staff to an efficient 5-event sheet, and a post fall "sticker" enhanced communication.Beyond data, our success is seen in the culture shift from a nursing isolated event to a transdiciplinary team approach to attack a complex clinical syndrome. We have heightened awareness of staff to provide a patient safe environment. Patient Fall Reduction Program has resulted in a significant decrease in falls with wide statistical variation in July 2003 of 7.7 to an entire 12 month period below target in 2006 with a low of 1.94 falls per 1000 patient days in April, minimized variation of data, and a trend line that continues downward along with the falls injuries.We are continuing with real time review of every fall and implementing additional Pharmacy changes. Our goal is to "Keep Our Patients Safe".

Full metadata record

DC Field

Value

Language

dc.type

Presentation

en_GB

dc.title

Transdisciplinary Approach to Fall Prevention

en_GB

dc.identifier.uri

http://hdl.handle.net/10755/147189

-

dc.description.abstract

<table><tr><td colspan="2" class="item-title">Transdisciplinary Approach to Fall Prevention</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Sigma Theta Tau International</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2007</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Larkin, Jill Marie, RN, MSN, MBA</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">UPMC Passavant and UPMC Passavant Cranberry</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Clinical Director of Professional Practice</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">larkinjm@ph.upmc.edu</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Cheryl V. Dodson, RN, MBA</td></tr><tr><td colspan="2" class="item-abstract">[Scientific session research presentation] Assessment completed through real time root cause analysis of every fall.&nbsp; Common risk factors identified prior to the fall included:&nbsp; polypharmacy, medications causing confusion/delirium, history of falls, mobility limitations, and toileting. We shifted from a nursing team to a transdisciplinary team consisting of Leadership, Physicians, Nursing, Pharmacy, Physical Therapy, Maintenance, Safety/Risk. Our focus shifted from falls being an isolated event to a complex clinical syndrome with potential for significant morbidity/mortality that needs to be recognized, evaluated, treated, and prevented.Education included interactive classes, online CME's, and &quot;Equipment Fair&quot;.&nbsp; A Post Fall Assessment Team responds to falls 24/7 to examine the risk factors' &quot;real time&quot;, serve as a resource, and implement strategies. Limiting sleeping medications on the formulary, administration time prior to midnight, and activating bed alarms was successful. To promote a positive culture, a reward program celebrates &quot;number of days&quot; departments are &quot;falls free&quot;.&nbsp; Documentation analysis resulted in the following improvements: admission order sheets revised to decrease automatic ordering of sleep/anxiety medications, assessment forms designed by staff to an efficient 5-event sheet, and a post fall &quot;sticker&quot; enhanced communication.Beyond data, our success is seen in the culture shift from a nursing isolated event to a transdiciplinary team approach to attack a complex clinical syndrome.&nbsp; We have heightened awareness of staff to provide a patient safe environment.&nbsp; Patient Fall Reduction Program has resulted in a significant decrease in falls with wide statistical variation in July 2003 of 7.7 to an entire 12 month period below target in 2006 with a low of 1.94 falls per 1000 patient days in April, minimized variation of data, and a trend line that continues downward along with the falls injuries.We are continuing with real time review of every fall and implementing additional Pharmacy changes.&nbsp; Our goal is to &quot;Keep Our Patients Safe&quot;.</td></tr></table>

en_GB

dc.date.available

2011-10-26T09:30:01Z

-

dc.date.issued

2011-10-17

en_GB

dc.date.accessioned

2011-10-26T09:30:01Z

-

dc.description.sponsorship

Sigma Theta Tau International

en_GB

All Items in this repository are protected by copyright, with all rights reserved, unless otherwise indicated.